Access to Emergency Care across the whole population

73. The indicators currently being collected by Integration
Authorities are:

Reduce emergency admissions to hospital (
NPF)

Accident and Emergency Waiting Times (
LDP)

Rate of emergency bed days for adults (
HSCII)

Readmissions to hospital within 28 days of discharge (
HSCII)

Percentage of total health and care spend on hospital
stays where the patient was admitted in an emergency (
HSCII)

Number of days people spend in hospital when they are
ready to be discharged (
HSCII)

74. Integration Authorities are developing local objectives and
plans in relation to the six agreed priorities identified in the
Scottish Government's Health and Social Care Delivery Plan
[12] (occupied bed days for unscheduled care; unplanned
admissions; A&E performance; delayed discharges; end of life
care; balance of care spend). As is appropriate, these plans are
being developed taking into account the local context of health and
social care services in their area. Some authorities are focussing
on the wider journey of care and this is particularly important in
dealing with patients presenting to A&E departments.

75. Considerable attention is paid to the performance against
the
LDP standard
that: "95 per cent of patients to wait no longer than 4 hours from
arrival to admission, discharge or transfer for A&E treatment.
Boards to work towards 98 per cent." This is an important standard
and should remain since there is strong evidence of poorer outcome
in patients who wait longer than 4 hours to be seen, treated or
discharged. However, the A&E episode is one stage in a
patient's journey along the unscheduled care pathway. Some
Integration Authorities report that they are collecting data on why
patients are presenting to A&E and examining whether enhanced
community based services, working in association with primary care
and social care including care homes might meet some patients'
needs more effectively. In addition, data on the outcome for
patients admitted is being collected and some Integration
Authorities are developing new services with specialist assessment
at an early stage for elderly patients to determine the most
appropriate level of care for them, thus facilitating early
discharge. At present, the evidence points to difficulties in
finding beds in hospital for patients requiring admission as the
main reason for waiting time breaching.

76. This approach embodies the recommendations for designing
targets and objectives advocated by Berry and colleagues in that it
is pragmatic, collaborative and iterative. Shared learning across
Integration Authorities will allow good practice to spread and this
approach to improvement should be supported. Much of the
information obtained from these indicators can be collected
accurately and timeously. It is suitable for a collaborative
improvement approach and it appears that several areas are already
working in this way.

77.
Recommendations:

a) All these indicators should remain. However, A&E
attendances should be seen as part of an unscheduled care
journey. Information on the number of attendances at A&E,
their referral pathways (
GP or self
referred) the length of time they spent in A&E, whether they
were admitted, how long they spent in hospital and what their
outcome was should be reported on regularly. Information on bed
availability in hospital should be reported as a key determinant
of long waits in A&E. Such data gives important contextual
information on demands on Emergency Departments and the
effectiveness of the whole system in managing such
patients.

b) Information on the number of patients from each
GP practice
attending A&E would give insight into opportunities to
develop other services such as new, holistic approaches to social
support or mental health support in association with primary
care. It is recommended that each
GP practice
receives regularly information on how many of its patients attend
A&E and how many self refer. As already indicated, this is
already happening in some
IJBs. Where
numbers are significant, additional support for those practices
should be considered.